The Transplantation Society’s Policy on Interactions With China

Annika Tibell

The Transplantation Society has for many years taken a stand against the use of organs from executed prisoners in the People’s Republic of China. Recently, increasing contact between Chinese transplant programs and the international transplant community has created a need for more specific guidelines. This article presents The Transplantation Society’s policy on interactions with China and also summarizes some recent positive developments.
(Transplantation 2007;84: 292–294)

The use of transplantation as treatment for patients with
terminal organ failure is gradually increasing. However,
patient access to organ and tissue transplantations varies
widely around the globe (1). Transplantation was first established
as a part of routine health care in North America,
Australia, and many parts of Europe. These countries are now
struggling with increasing waiting lists due to a large gap between
the number of available organs and the demand. The
main reason for the increase in recent years is a growing number
of procedures carried out in developing regions. Complete
international statistics of transplantation procedures are
lacking and the World Health Organization (WHO) is presently
collecting data worldwide. However, it has become obvious
that the People’s Republic of China (referred to as
China in the following text) now has one of the largest transplant
programs in the world, with about 11,000 organ transplantations
performed in 2005.

Since the late 1980s, there have been multiple indications
that executed prisoners are the main (and, more or less, only)
source of organs and tissues in the Chinese transplant programs.
This has now also been officially acknowledged by a representative
of the Chinese government. The Transplantation Society
(TTS), as well as other professional societies and human rights
organizations, previously condemned this practice in the 1990s;
the membership statement of TTS has long stipulated that no
member should be involved in obtaining or transplanting organs
procured from executed prisoners.

There are many reasons for this position. TTS considers
it a basic requirement that the act of donation is voluntary.
Moreover, the decision to donate must be based on relevant
and sufficient information and made without external pressure
or coercion. Even if a death-sentenced prisoner and his
family were given such information, the situation makes it
impossible to ascertain whether the decision was independent
and free. Furthermore, in accord with the position of many
medical societies, including the American Medical Association,
a physician—as member of a profession dedicated to
preserving life—should not participate in a legally authorized
execution (2).

Another problem is the commercialization of transplantation
procedures that has occurred at least in some parts
of the Chinese health care system. The first reports on transplantations
in foreigners who paid to obtain kidney transplants
retrieved from executed prisoners were published
more than 15 years ago (3, 4). During recent years, several
hospitals have placed advertisements on the World Wide
Web to attract transplant recipients from abroad. The information
has emphasized the short waiting times and, in some
cases, has guaranteed a second transplant within a few weeks
in case the first graft fails. No statistics are available on the
number of foreign citizens undergoing transplantations in
China, but it seems obvious that the increased transplantation
activities have not been solely directed towards the own
population. The financial gain for the parties involved raises
concern that money may become an incentive to increase the
number of organs available for transplantation, and that this
might affect the use of death sentences or the number of
crimes for which such sentences can be applied.

The Need for Guidelines
The ethical issues were highlighted during the World
Transplant Congress in Boston, July 2006. During this meeting,
a new Ethics Committee of TTS was appointed. The
chairman of the previous committee, Dr. Francis L. Delmonico,
remains as a committee member and was also appointed Director of Medical Affairs.
One of the first tasks for the committee was to revise the Membership Statement of
TTS to further underline the importance that all donations
and transplantations should be performed within a legal and
ethical framework that protects living donors and ensures
that organs from deceased donors are recovered only when
consent for donation has been obtained (5). As previously,
the statement condemns the buying and selling of organs.
Every new member must agree not to be involved in the transplantation
of organs from executed prisoners or other donors
where there is a risk that an autonomous consent for donation
is lacking. The positions of TTS are further described in
the Society’s new Policy and Ethics Statement (6).

The political developments in China, with more openness
towards the international community, have increased
the number of requests and invitations to collaborate with
Chinese transplant programs in various ways. The Transplantation
Society Council found that specific guidelines are
needed for interactions with China. The Ethics Committee
chose to develop a statement formulated as responses to the
most common questions. After approval of the TTS Council,
the document was distributed to its membership. The complete
document is shown in Figure 1.

The main aims were to support the positive developments
in China, but at the same time stress that their present policies
were considered unacceptable, and to maintain international
pressure towards a change. For these reasons, doctors and health
care personnel involved in obtaining or transplanting organs
and tissues from executed prisoners cannot become members of
TTS. Likewise, scientific presentations from such transplant centers
involving patient data or samples from recipients of organs
from executed prisoners cannot be accepted for presentation at
TTS meetings and TTS members should not collaborate in such
studies. However, to promote dialogue and insight into international
practice, doctors and health care personnel from China
may be accepted as registrants at TTS meetings. TTS members
can also accept invitations to lecture in China and provide expertise
if the activity favors the development of Chinese transplantation
programs towards TTS standards of practice. Clinical
and preclinical trainees from China should be accepted only if
they are educated in appropriate alternatives to the use of executed
prisoners and agree to comply withTTS standards of practice
throughout their careers.

After lengthy discussions, it was finally decided to recommend
that international registers accept data about patients
transplanted with organs or tissues from executed prisoners. The
reasons for this decision were the need for transparency and the
collection of correct demographic data. However, the fact that
the organs and tissues were obtained from an executed prisoner
should always be clearly stated and such data should not be used
for scientific registry studies. This document undoubtedly fails
to deal with all possible situations. However, if one is uncertain
about collaboration with representatives of a Chinese transplantation
program, one should always be guided by the principle
that TTS supports collaboration that contributes to a development
towards internationally accepted standards of care.

In July 2006, a report on the alleged harvesting of organs
from practitioners of Falun Gong in China attracted major international
attention (7). The authors were two Canadians:
David Matas, an immigration, refugee, and international human
rights lawyer; and David Kilgour, former member of Parliament
and a former Secretary of State for the Asia Pacific region. The
investigation was done from outside China and was based on
interviews and the assessment of available written information.
It is alleged that organs have been obtained from many unwilling
Falun Gong practitioners and that the individuals were not executed,
but instead killed during the course of the surgical recovery.
The Chinese authorities deny that any such activities have
occurred. TTS considers this report alarming but has no possibility
to further investigate the accusations. Instead, TTS has
made a formal request to the WHO that the United Nations
Commission for Human Rights investigates these charges.

During 2006, TTS established an official collaboration
with WHO. One important task is to cooperate with government
agencies and create national legal frameworks that comply
with TTS standards of practice and guiding principles of
the WHO. In China, TTS together with WHO works directly
with the Vice Minister of Health. According to the Vice Minister,
the Chinese government now intends to create a legal
framework for national oversight, ban the purchase and sale
of human organs, and prevent organ trafficking and transplant
tourism. Credentials for Chinese transplant officials
will be established, only selected centers will be allowed to
perform transplantations, and transplantations on foreign
citizens will be subjected to special regulations. The Chinese
government also states that deceased organ donation based
on brain death criteria will be established with the intention
of achieving a national self-sufficiency that includes deceased
and living donors.

TTS endorses this development and looks forward to
the implementation of these new policies in China. The establishment
of deceased organ donation from donors with
total brain infarction and a careful expansion of live donor
programs hopefully will create a basis for reevaluation of the
practice of using executed prisoners.

1. Council of Europe. International figures on organ donation and transplantation
activity. Newsletter Transplant 2005; 10: 5–22.
2. Current Opinions on Capital Punishment. Chicago: The Council on
Ethical & Judicial Affairs of the American Medical Association, 1989.
3. Guttman R. On the use of organs from executed prisoners. Transpl Rev
1992; 6: 189–193.
4. Cheng IKP, Lai KN, Au TC, et al. Comparison of the mortality and
morbidity ration between proper and unconventional renal transplantation
using organs from executed prisoners. Transpl Proc 1991; 23:
5. Membership Statement. Ethics Committee of the Transplantation
Society. Available at:
downloads/TTS_Ethics_Policy.pdf. Accessed 1 June 2007.
6. Policy & Ethics. The Transplantation Society. Available at: https:// Accessed 1 June 2007.
7. Matas D, Kilgour D. Report into allegations of organ harvesting of
Falun Gong practitioners in China. Available at: https://www.davidkilgour.
pdf. Accessed 1 June 2007.

CLINTEC, Division of Transplantation, Karolinska Institutet, Karolinska
UniversityHospital, Stockholm, Sweden.
Address correspondence to: Annika Tibell, M.D., Ph.D., Chair of the Ethics
Committee of The Transplantation Society, Department of Transplantation
Surgery, Karolinska Institutet, KarolinskaUniversityHospital, 141
86 Stockholm, Sweden.
E-mail: [email protected]
Received 30 March 2007. Revision requested 4 May 2007.
Accepted 8 May 2007.
Copyright © 2007 by Lippincott Williams & Wilkins
292 Transplantation • Volume 84, Number 3, August 15, 2007
© 2007 Lippincott Williams & Wilkins